Tom is 50-year-old male who presents with distal lateral subungual onychomycosis of his left great toe.

He has had
symptoms for four months. On exam, he also appears to have interdigital tinea pedis.
Referring to clinical guidelines, what is the first-line treatment for both tinea pedis and onychomycosis in
adults?
Based on the presentation of the patient, the has a diagnosis of subungual onychomycosis on the left great toe along
with interdigital tinea pedis. As per the current AAFP treatment guidelines, the patient should be initiated on Terbinafine
250 QD x 12 weeks for treatment of toe infection. Terbinafine can also be used for treatment of tinea pedis, such that
the treatment would overlap coverage. However prior to initiation of treatment, a KOH prep should be performed to
determine the etiology of the onychomycosis as approximately 50% are of fungal etiology. As per the American
Academy of Dermatology, the treatment should not be initiated prior to confirmation of the etiology of infection.
Additionally treatment of onychomycosis in adults in not usually recommended and usually initiated due to cosmetic
reasons or pain.
What medication precautions does the patient need to be educated on?
The patient should be educated cleaning footwear, not sharing foot wear, maintaining a dry and clean foot.
What kind of follow-up does the patient require?
The patient should be educated that the recurrence and treatment failure rates of onychomycosis are high and since
the toe nail grows slowly, it takes approximately 9-12 months to cure.

2nd assignment
Clementine is a 48-year-old female who has had right ear pain and fullness for the past week that is worsening. She
has felt hot but has not taken her temperature. In the office, her temperature is 101, and her TM is red, bulging, and
painful to examination. The canal is red and stenosed. Your impression is otitis media and externa.

What is your treatment plan for her and why?

Given the patients symptoms, marked with right ear pain, fullness, pyrexia, red bulging TM w/t stenosis of the external,
the patient is presenting with acute otitis media with externa. The patient should be initiated on antibiotic therapy to
prevent further complications of AOM w/t Externa. Initially the recommended therapy is Amoxicillin-Clavulanate 500mg
q 12h for a total of 10 days. Additionally patient can also be given analgesics for management of pain and anti pyretics
for fever.
What patient teaching should you provide?
Patient should be educated on receiving vaccinations especially pneumococcal, along with handwashing, smoking
cessation.
Why did you choose this teaching?
Handwashing can help limit spread of AOM and inoculation of the contralateral ear, and since AOM/OME is a symptom
of URI smoking cessation is helpful in limiting recurrance